Talking Telemedicine: Is the Interactive Voice-Logbook Evolving into the Cornerstone of Diabetes Healthcare?

Transcription

1 Talking Telemedicine: Is the Interactive Voice-Logbook Evolving into the Cornerstone of Diabetes Healthcare? Black, L., McTear, M., Black, N., Harper, R., and Lemon, M. Faculty of Engineering, University of Ulster at Jordanstown, Northern Ireland. Presentation Overview Problem Definition Introducing the System Highlight Design Features & Considerations Integration and Testing Methodology Results Conclusion 1

2 Type 2 Diabetes and Hypertension- combining conditions Nearly 50,000 affected by Type 2 diabetes in Northern Ireland. It is estimated at least 60% of these patients have co-existing hypertension Frequently no symptoms Complications NHS costs 5.2 billion per annum (Tardis Report) UKPDS trials advocate regular monitoring More people will get the disease (aging population, sedentary lifestyle, unhealthy diet = more obese patients) Lack of control and communication (paper logbook) Home Monitoring; A Twofold Perspective Patients View Lack of regular contact, support & education from the point of care Compliance is an arduous task (forget medication, feel controlled) Paper logbook is static - does not promote advice, feedback, incentive Physician Perspective Less than ¼ of patients make necessary lifestyle changes Lack of time, financial, human resources, accountability More patients, more information generated Paper logbook often incomplete, illegible Doctors do not like entering data 2

3 Diabetes Management Solutions DIABNET- knowledge-based system which produces advice on insulin therapy adjustments and diet recommendations for patients with gestational diabetes. Patients use palm-top computers. IDEATel - Disease management program in rural and urban underserved areas. Home telemedicine unit used for blood glucose downloading and videoconferencing. DIABCARD - Uses smart cards as means of collecting patient data. Clinician uploads data to cards at the point of care. DIAMOND - Diabetes electronic patient management (EPR) system used by 40 health institutions in UK DI@L-log Prototype A spoken dialogue system for the acquisition of type 2 diabetes (T2DM) home monitored patient data is proposed, known as DI@L-log. The purpose of the system is to collect: Weight Blood sugar Blood pressure readings from hypertensive T2DM patients on a weekly basis using their home telephone. The system incorporates the latest speech technologies in conjunction with artificial intelligence techniques. 3

4 Why the Telephone in Medicine? The PSTN is the simplest and oldest form of telemedicine As a neutral source of empowerment over the paper logbook Overcome constraints of space and time No expert knowledge or modem required (microphone/speaker as input-output devices) Ubiquitous - more telephone lines than computer terminals Practical- extends to remote/isolated areas (24/7) User has choice of input (Speech or DTMF) More cost effective than some exclusive technologies (many patients from socially deprived backgrounds) DI@L-log Voice Logbook DI@L-log is intended as an autonomous communication intervention whose design improves the traditional paper logbook used to document home readings by the patient, via a seamless medical information exchange infrastructure that scales to the needs of multiple end users. System architecture integrates VoiceXML + PSTN, with a Pan-European open architecture for hosting integrated telephony applications. TCP/IP connections to a database enable patient information to be dynamically updated and relayed to the point of care EPR. 4

5 Design Characteristics is a female, application-directed system -Supports speaker independent interaction -Adaptive to novice & expert users (Full Duplex) -Explicit confirmation protocol at each interaction to minimize ambiguity -Universal navigation help, repeat & exit commands -Uses a variety of incremental and tapered prompts 5

6 Task Model Sequence and Event Handling Technology and Tools Employed VUI (Voice User Interface) VoiceXML 2.0 XML coded grammars (custom, built-in and DTMF) VoxPilot- Internet Voice Browser provider Backend Subsystem MS Access Database via ODBC Apache Tomcat 4.0 JSP SQL GUI (Graphical User Interface) Visual Basic 6.0 Photoshop 6

7 Requirements Analysis and Testing Methodology Questionnaires to T2DM patients (n=32) at UCHT to determine user needs and profiles demographics, compliance issues, use of mobile and standard telephones, computer literacy and impressions of Spoken Dialogue Systems (SDS)and collect word vocabulary. Focus group sessions held, training of devices provided. WOZ and rapid prototyping techniques employed on patients (n=5) and a combination of health professionals and academic peers (n=7) in development of VUI and GUI. Simulations were then fed to the system of real patient data sets (n=10) from a 3 year time frame to test accuracy of decision support functionality There is a pre-pilot study currently underway Full 6-9 month pilot will be rolled out to 20 T2DM patients from Institute of e-health at the Ulster Hospital in January. System Intelligence & Domain Knowledge Specific order created for users to acquire consistent mental model Production rules written according to medical protocols, refined by medical experts. Protocols and domain knowledge used to compute differences from one week to the next by consulting previous patient measurements and user targets held in the database SCALES Weight-Ideal weight / BMI METER Blood sugar- HbA1c NICE Guidelines BP CUFF Blood Pressure BHS Protocol 7

8 Rule Based Intelligence Thresholds Feedback - data is dynamically updated using JSP and relayed to the Hospital - given in real-time to patient once all 3 values entered - designed to be proactive, not to intimidate - provides concise relevant information and a Call to Action to empower patients, System: The system will now update and process your new data. Your weight is falling and your blood sugar is well controlled. However, the blood pressure reading is slightly higher than the last time. If you can include some exercise, for example, 20 minutes of walking each day, this will help to lower your blood pressure. Also remember to reduce both salt and sugar intake at meal times. Well done, and keep up the good work! Thank you for calling the Dialogue Interactive Service. Please call again next Monday... Goodbye. Patient: Goodbye. 8

9 Human Factors and Considerations Diverse user populations patients and physicians Cognitive demands and restrictions (motor, perceptory skills). Each user has individual needs personalise the interaction Patients will include the elderly, disabled and infirm A clear mental model is necessary to familiarise patients with the Voice Logbook No visual cues or icons- therefore consistency in prompts, and appropriate event handlers User expectations from science fiction/attitudes and preconceptions. Speech is transient, linear listening slow, communication is incremental; language ambiguity (eg accents) Ethical/security considerations (DTMF Keypad) Pin and passwords. VoiceXML incorporates SSL Voxpilot facilitates ANI tracking to validate callers Voice enrolment also considered. Initial Results Most calls last 2-3 minutes in duration The average user takes nine turns to complete tasks-initially moderate level of recognition failures with digit input Callers prefer female voice over the male voice A personalised system (i.e. that greets the user by name) rather than formal system was preferred Every caller has been confident in speaking to the system, (however female subjects possibly more shy) and will revert to DTMF keypad where input hasn t been recognised via speech Peers have found the DI@L-log easy to use, and patients like the idea of a system that is not a real consultant monitoring them. 9

10 The Graphical User Interface Iteratively designed with health team Target markers illustrate where reading ranges should be Documents temporal data parameters trends Complements decision support/evidence based practice Additional Alerts functionality for abnormal trends/ 10

11 Alerts There are 2 alert categories medium and high. Promote sense of shared responsibility Alert facility promotes earlier intervention and prevention of complications For example: Blood sugar If reading falls into category 4 for any two of three consecutive calls to the system, generate alert to caller Your blood sugar is still too high. Your diabetes team has been informed and will contact you shortly". Presence of alert recorded in Patient table in database. 11

12 Evaluation and future work System performance and usability evaluation using qualitative and quantitative metrics. Does the system impinge on health professionals workflow practices? Improved patient quality of life & incentive? Show potential evidence for reduce costs of healthcare delivery? Conclusions aims to improve the quality of diabetes care and establish appropriate techniques to accommodate individual patient preferences via an innovative speech communication platform that extends to a vast user audience. The autonomous nature of the system aims to replace the passive paper logbook and give patients empowerment and more responsibility in actively caring for their condition. Using telephony and spoken dialogue technology has many potential benefits over the static paper logbook or the GUI. It is argued that the provision of home monitored snapshots via spoken dialogue telemedicine technologies is timely and complementary to the evolving patient-centric models of healthcare delivery i.e. keeping patients at home. 12

13 Acknowledgements And special thanks to And special thanks to John Kennedy - Microsoft Corporation, USA Tim Bennett- DIAMOND EPR, UK George Fox - Voxpliot Conor McMeel 13